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8.In regards to your mental health, including stress, depression, and problems with emotions, how many days during the past 30 days was your mental health NOT good?

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9.During the past 12 months, what has been the biggest source of stress in your life?

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10.In the past 12 months, did you receive counseling or treatment for mental health concerns?

Yes

No

Don’t know/not sure

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11.If you felt you needed mental health treatment or counseling but did not receive it, what was the primary obstacle preventing you from receiving care?

I could not afford the cost

I was concerned that getting mental health treatment or counseling might cause my neighbors, or community to have a negative opinion of me

I was concerned that getting mental health treatment or counseling might have a negative effect on my job

My health insurance does not cover any mental health treatment or counseling

My health insurance does not pay enough for mental health treatment or counseling

I did not know where to go to get services

I was concerned that the information I gave my counselor might not be kept confidential

I was concerned that I might be admitted to a psychiatric hospital or might have to take medicine

I did not need treatment

Other (please specify)

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12.How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists.

Less than 12 months

1-2 years

2-5 years

5 or more years

Don’t know/not sure

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13.How many of your permanent teeth have been removed because of tooth decay or gum disease? (This includes teeth lost to infection, but not teeth lost for other reasons, such as injury or orthodontics. )

None

1-5

6 or more

All

Don’t know/not sure

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14.During the past 12 months, how often did you have to cut meal sizes or skip meals due to insufficient money for food?

Once a week

Once a month

A few times a year

Once a year

Never

Other (please specify)

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15.Do you currently have any kind of healthcare coverage, including health insurance, prepaid plans (HMOs), government plans (Medicaid/Medicare), or Indian Health Services?

Yes

No

Don’t know/not sure

Refused

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16.Of the following support services, which one do YOU most need, that you are not currently getting?

Classes about giving care, such as giving medications

Help in getting access to services

Support groups

Individual counseling to help cope with giving care

Respite care

I don’t need any of these support service

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17.During the past 30 days, have you participated in any physical activities or exercise such as running, biking, calisthenics, or walking for exercise?

Yes

No

Don’t know/not sure

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18.If there was a time in the past 12 months when you needed to see a doctor but could not, what obstacles prevented you from receiving care? Select all that apply.

I did not need to see the doctor

Did not have difficulty accessing health care

I could not afford the cost

Lack of time

No doctor appointments available

Lack of transportation

Did not know where to seek care

Lack of employer flexibility

Don’t know/not sure

Other (please specify)

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19.How often do you currently use tobacco products, such as chewing tobacco, cigarettes, snuff, or snus?

Every day

Most days

Rarely

Not at all

Don’t know/not sure

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20.How often do you currently use e-cigarettes or other electronic “vaping” products?

Every day

Most days

Rarely

Not at all

Don’t know/not sure

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21.During the past 30 days, how many days did you have at least one alcoholic beverage such as beer, wine, a malt beverage, or liquor?

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22.In the past seven days, how many days did you exercise for at least 30 minutes?

6-7 days

4-5 days

1-3 days

None

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23.During the past 30 days, how many times per day and per week did you eat fruit? Count fresh, frozen or canned fruit, NOT juice.

0

1-2

3-4

5+

Unknown/ Not sure

Times per day

Times per day 0

Times per day 1-2

Times per day 3-4

Times per day 5+

Times per day Unknown/ Not sure

Times per week

Times per week 0

Times per week 1-2

Times per week 3-4

Times per week 5+

Times per week Unknown/ Not sure

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24.If you did not eat fruit in the past 30 days, please explain why. If you did, please skip to the next question.

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25.During the past 30 days, how many times per day, and per week, did you eat green vegetables such as broccoli romaine, chard, collard greens or spinach?

0

1-2

3-4

5+

Unknown/ Not sure

Times per day

Times per day 0

Times per day 1-2

Times per day 3-4

Times per day 5+

Times per day Unknown/ Not sure

Times per week

Times per week 0

Times per week 1-2

Times per week 3-4

Times per week 5+

Times per week Unknown/ Not sure

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26.If you did not eat greens in the past 30 days, please explain why. If you did, please skip to the next question.

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27.In the past 12 months, how often did alcohol use, by you or another member of your household, cause stress, conflict, or anxiety for you?

Once a week

Once a month

A few times a year

Once a year

Never

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28.Do you currently have enough non-perishable food, water, medical supplies and other supplies (e.g. flashlights, radio, batteries, etc.) at your home to be able to stay in place during an emergency or disaster for up to 3 days?

Yes

No

I don’t know

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29.Do you have an established emergency or disaster plan (Actions you would take, including how you would communicate with family or friends during an emergency) for you and your family?

Yes

No

I don’t know

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30.What is your home zip code?

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31.Indicate your gender.

Male

Female

Transgender

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32.Indicate your race/ethnicity.

Asian or Pacific Islander

Black/African American

Hispanic/Latino

American Indian/Native American

White/Caucasian

Other (please specify)

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33.Select the category that includes your age.

Under 18

18-24

25-34

35-44

45-54

55-64

65 or above

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34.What is your marital status?

Married

Living together, unmarried

Divorced

Separated

Widowed

Never been married

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35.What is your highest level of education?

K-8th grade

Some high school

High school degree

Technical school

Some college

Associate’s degree

Bachelor’s degree

Graduate school

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36.In 2016, what was your annual household income from all sources?

Less than $10,000

$10,000 to under $25,000

$25,000 to under $50,000

$50,000 to under $75,000

$75,000 to under $100,000

$100,000 or more

Prefer not to say

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37.How many children live in your household? If none, write 0.

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38.Would you like to provide us with your name and contact information to be entered into a drawing for a Kindle Fire?

***Your survey answers are not part of a HIPAA protected medical record, however your contact information will be kept confidential.***

Yes

No

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39.THIS IS VOLUNTARY. Your survey answers are not part of a HIPAA protected medical record, however any and all contact information will be kept confidential.